Provider Demographics
NPI:1407451545
Name:GADOMSKI, KRISTINA BETH
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:BETH
Last Name:GADOMSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8914 STATE ROUTE 60
Mailing Address - Street 2:
Mailing Address - City:WAKEMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44889-9005
Mailing Address - Country:US
Mailing Address - Phone:440-935-1404
Mailing Address - Fax:
Practice Address - Street 1:3530 WESTGATE # D-432
Practice Address - Street 2:
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-1300
Practice Address - Country:US
Practice Address - Phone:440-356-4265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHF11200168363LF0000X
OHAPRN.CNP.0028147363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily